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Intimate Partner Violence

GO BEYOND CHECKING THE BOX

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Introduction

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My Background

  • EMS Provider since 1991
  • NYS Paramedic since 2012
  • NYS CIC since 2011
  • Nationally certified PA since 1995
  • Clinical Practice-Mobile Surgical Services for Rochester Regional Health
  • Director of Didactic Education at developing Ithaca College PA program

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Instructional Objectives

  • Objective 1: Recognize common signs and symptoms of intimate partner violence.��Objective 2: Demonstrate non-judgmental communication skills when screening for IPV.��Objective 3: Identify and utilize IPV resources that are available in their local community.

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Disclaimer

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A Case Study

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The Life of Joy

  • 25 year old female
  • Met her husband 6 years ago, married 2 years ago
  • He calls her frequently throughout the day to “check in”
  • Sometimes gets upset when she doesn’t answer
  • One day, she notices her computer isn’t working correctly-repair place tells her it has spyware
  • A few months later, she notices money missing from her checking account, her husband tells her the bank made an error
  • She is invited to go out with friends, her husband requests that she stay home for “date night”

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Definition of IPV

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Definition of IPV

  • Refers to a pattern of behaviors that one person in an intimate partner relationship uses against the other person in the relationship to try to establish and maintain power and control.
  • Involves current or previous:
    • Spouses
    • Romantic partners who live/lived together
    • Fiancés/Fiancées
    • Dating Partners

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History of IPV

  • 750 BCE – “Rule of Thumb”
  • 300 CE – Constantine the Great’s demonstration
  • “Wife battering” not an official crime until 1945, however,…
  • 1970s – research by data collection validated the problem of IPV
    • Shelter for battered women appeared
    • Terms such as woman battering and domestic violence emerged
                  • - Indiana Coalition Against Domestic Violence, 1999

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Consequences of IPV

  • Physical maladies
  • Mental disabilities
  • Unintended pregnancies
  • STIs
  • Lack of feeling safe
  • Lack of work productivity – lowered SES
  • Burden for society, > 8.3 million healthcare dollars each year

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Risk Factors for IPV

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Victims of IPV come from every:

  • Age group
  • Religion
  • Ethnic/racial group
  • Socioeconomic level
  • Educational background
  • Sexual orientation

There is no single profile of an abused woman or perpetrator

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Victim Risk Factors

  • **Being a victim of child abuse or witnessing parental IPV
  • Age < 24 (here in NM 26-35)
  • Low self esteem
  • Poverty
  • Not being married

  • Having young children in the home
  • Having multiple sexual partners
  • Pregnancy (yes and no)
  • History of being raised with violence at home

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Victim Risk Factors

  • Ethnicity
    • Higher prevalence, incidence and recurrence of IPV among African American and Hispanics couples than White couples.
  • Special populations
    • immigrant women, women with disabilities, the elderly
  • Alcohol consumption and alcohol problems
  • Less education
  • Living within a community or family with male dominant norms

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Characteristics of Perpetrators

  • 26-35 years old
  • Presence of high levels of hostility
  • Low level of assertiveness
  • High need for control
  • Impulsiveness
  • Inability to regulate behavior such as aggression

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Risk Factors for Homicide

  • Abuse in a previous relationship
  • Leaving the abuser, or even the threat of leaving
  • Stalking
  • Being strangled prior
  • Availability of handguns and other weapons, especially when coupled with ETOH
  • Perpetrator’s change in behavior
  • Loss in control over the victim
  • Barriers to help
                  • Sheehan, et. al, (2015)

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Stories from Family Members of IPV Homicide Victims

    • She couldn’t escape him no matter where she moved
    • There was an increase in their arguing; she told him their marriage was over
    • Extreme jealousy
    • Barriers to help
      • By perpetrator
      • Isolation
      • By the justice system, social and mental health organizations
      • By healthcare providers

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Patterns of IPV

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Methods of Control

Physical abuse:

  • Hitting, pushing
  • Shoving, slapping, punching
  • Holding or restraining
  • Strangling, choking
  • Inflicting bruises
  • Welts and lacerations
  • Dragging, pulling by hair
  • Restraining
  • Marking, branding

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Emotional abuse:

  • Threatening, intimidation
  • Humiliation
  • Extreme jealousy/possessiveness
  • Threatening acts of violence
  • Constant criticizing
  • Insulting and belittling
  • Ignoring or dismissing the victim
  • Denying, minimizing and blaming
  • Invading privacy

Methods of Control

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Sexual abuse:

  • Coercing victim to have sex
  • Making victim watch pornographic movies
  • Sexually transmitted diseases
  • Demanding sexual photos
  • Using date rape drugs
  • Sabotaging birth control

Methods of Control

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Financial abuse:

  • Withholding money
  • No access to bank accounts/ATM and credit cards
  • Ruining victim’s credit
  • Taking pay check
  • Gambling

Methods of Control

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Technology abuse:

  • Tracking location
  • Demanding check-ins
  • Excessive texts
  • Spyware
  • Spoofing, catfishing
  • Monitoring communications
  • Posting on Facebook and social media

Methods of Control

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Legal abuse:

  • Constant threats to gain custody of children
  • Excessive filing of motions at court
  • Using parental rights to contact victim
  • Reports to child protective services

Methods of Control

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IPV in Specific Populations

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Frequency of IPV

  • Experiences of IPV are reportedly 2 to 4x more frequently by respondents identifying as:  
  • LGBTQ 
  • Of transgender experience and non-binary gender
  • Multi-racial nH/nL, American Indian/Alaska Native, Black nH/nL, Asian nH/nL, and Hispanic/Latinx 
  • Having a disability 

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IPV and Pregnancy

  • More likely to escalate and experience all and more severe forms of violence
  • 3-fold risk of being murdered
  • Increased risk for complications during pregnancy

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Consequences of IPV

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Health Effects of IPV

  • Injuries
  • Headaches
  • Insomnia
  • Chronic pain
  • Choking sensations
  • Hyperventilation
  • Gastrointestinal symptoms
  • Chest pain
  • Back pain
  • Pelvic pain
  • TBI
  • Nonfatal strangulation
  • Unplanned pregnancies/pregnancy complications
  • STIs
  • Substance use disorders 

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Child Witnesses

  • 1/3 of reported IPV cases involved at least 1 child witness
  • 1/3 of the children experienced physical abuse, 15% experienced sexual abuse from the offender
  • Children who witness abuse are:
      • 3x more likely to think about suicide and be told they have a substance abuse problem
      • 4x more likely to experience child abuse
      • 4x more likely be told they have a mental illness and attempt suicide
      • six times more likely to be abused as an adult

                  • Caponera, 2016

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Effects of Witnessing IPV as Children

  • Risk of becoming a future IPV victim or perpetrator
    • Aggression
    • Disengagement
    • School absence
    • Depression
    • PTSD
    • Poor self-image
    • Poor health

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Screening for IPV

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Practitioner Barriers

  • Lack of awareness and education
  • Not wanting to open Pandora’s box
  • Uncertain of how to intervene
  • Protecting oneself so not to listen to painful depressing events
  • Feeling of helplessness at not being able to fix or change the situation
  • Time challenge

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Role (Responsibility) of the Provider

  • Screen
  • Understand who is at risk of becoming a victim
  • Assess level of danger
  • Give appropriate and safe advice
  • Refer to local agencies
  • Identify other family members at risk, especially children

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Validated Screening Tools

  • Abuse Assessment Screen (avail in Spanish)
    • 5 questions
  • Danger Assessment
    • 15 items to assess danger of homicide (available in Spanish)
  • HITS (hurt, insult, threaten, and scream)
    • 4 items
  • WAST (Quick!)
    • Short version (2 items)
    • Spanish version (8 items)
                  • Basile, Hertz, Back, 2007

https://www.cdc.gov/violenceprevention/pdf/ipv/ipvandsvscreening.pdf

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WAST Screening Questions

Option 1

Option 2

Option 3

In general, how would you describe your relationship?

A lot of tension

Some tension

No tension

Do you and your partner work out arguments with:

Great difficulty

Some difficulty

No difficulty

WAST Post-Screening Survey

Do arguments ever result in you feeling down or bad about yourself

Often

Sometimes

Never

Do arguments ever result in hitting, kicking, or pushing?

Often

Sometimes

Never

Do you ever feel frightened by what your partner says or does?

Often

Sometimes

Never

Has your partner ever abused you physically?

Often

Sometimes

Never

Has your partner ever abused you emotionally?

Often

Sometimes

Never

Has your partner ever abused you sexually?

Often

Sometimes

Never

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Assessing Immediate Risk of Violence

  • Has the physical violence happened more often or gotten worse in the last 6 months?
  • Has he/she ever used a weapon or threatened you with a weapon
  • Has he/she ever tried to strangle you?
  • Do you believe he/she could ever kill you?
  • Has he/she ever beaten you when you were pregnant?
  • Is he/she violently and constantly jealous of you?
  • “Yes” answers to at least 3 of these questions
  • may indicate immediate danger of violence

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Safety Plans for IPV

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The Frequently Told Story:

Seduction and Charm

    • Interested in “me”, supportive, and loving…
    • Intimacy, the importance of “us”, sacred relationship…

Isolation

    • Move away from others
    • Less contact with family and friends
    • Limit access to finances or resources

Violence or the Threat of Violence

    • Availability of weapons
    • Physical or sexual assault

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“Why stay?”

  • Hope that things will get better.
    • On average, victims deal with IPV 5-7x before leaving
  • Disappointing friends, family or community.
  • Lack of resources to care for self or child(ren).
  • Religious or cultural beliefs.
  • Immigration Status.
  • Belief that they can keep themselves and child(ren) safe.
  • Fear of being hurt or killed.

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It’s Easy to Say “Just Leave”

Despite the common belief that survivors of intimate partner violence (IPV) can exercise control over their circumstances, access to social and economic resources affects survivors' ability to attain safety.

There is also a tendency to focus on physical injury as the only impact of IPV, however, IPV also affects mental health and multiple other life domains.

Some groups are at higher risk, but IPV affects people of all backgrounds (genders, races, ethnicities, ages, sexual orientations, disability statuses, educational backgrounds, incomes, etc.).

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Significant Worries

  • Housing, utilities, debt, vehicles, insurance, and school tuition/daycare expenses
  • Household, medical/healthcare, technology, and childcare needs
  • Fear of loosing the partner who at this point may be the only one providing for her and/or children
  • Isolated without transportation
  • Fear the partner will find out and retaliate
  • Poor experiences in the past when the abuse has been divulged
  • Embarrassed
  • Fear of being deported
  • Having grown up with a culture of family violence and not recognizing it as wrong

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Maslow’s Hierarchy of Needs

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Key Components

Intimate Partner Violence

Violence Support Services

Employment

Housing

Basic Needs

Mental Health

Healthcare Access

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Talking with your patient (victim)

  • Screen privately (alone) and assure confidentiality
  • Talk in a manner that is understandable and that you are comfortable with
  • Listen without interruption
  • Provide a nonjudgmental and supportive environment

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You do not need to:

  • Solve the victim’s problems
  • Convince the victim to leave a violent relationship
  • Convince the victim to go to other services such as the police and the courts
  • Ask detailed questions that force the victim to relive painful events
  • Ask the victim to analyze what happened or why
  • Pressure the victim to tell you her feelings and reactions to an event
  • These actions could cause more harm than good

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EMPOWER

  • Empathic listening
  • Making time to properly document findings
  • Providing information about IPV
  • Offering option and choices
  • Working with an abuse specialist
  • Encouraging planning for safety and support
  • Referring to local services

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Plan

Listen

Inquire about needs and concerns

Validate

Enhance safety

Support

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Safety Plan Discussion

  • Safe place to go
    • If you need to leave your home in a hurry, where could you go?
  • Planning for children
    • Would you go alone or take your children with you?
  • Transport
    • How will you get there
  • Items to take with you
    • Important documents, immunization records, keys, money, clothes, essential items. Do you have access to money if need to leave in an hurry?
  • Support of someone close by
    • Is there a neighbor you can tell about the violence who can call the police or come with assistance for you if they hear sounds of violence coming from your home?

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Documentation

  • Tell what you want to document and ask permission to do so
  • Use victim’s words, not yours when possible
  • If you take pictures, include pt.’s name, location of injury and name of photographer
  • Enter in the EMR any health complaints, signs, symptoms
  • Measure and describe injuries
  • Don’t document heat of the moment statements such as “I swear I’ll kill him”

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Back to Our Case Study

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The Life of Joy

  • Her husband claims he is ready to start a family
  • She expresses uncertainty
  • One day, she can’t find her birth control pills and she assumes she misplaced them
  • One day, she tries to reach him at work and finds out that he isn’t there
  • When he comes home, she confronts him and tells him that she is leaving
  • He becomes violent, punching a hole in the wall

Were there signs of IPV in this relationship?

Is she in immediate danger?

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In Conclusion

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In Summary

IPV survivors are more likely to experience:

    • Job loss, reduction in work hours, and the need to take leave
    • Concerns about housing stability, paying expenses, and meeting basic needs
    • Poor mental health AND face structural barriers to accessing needed healthcare

Lack of social and economic resources and access to care both exacerbate the impacts of IPV and make survivors more vulnerable to further abuse

Continuing digital outreach and service provision approaches may expand access to resources for survivors in the context of a pandemic and after; access to technology and broadband is critical

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Options for Mental Health Support

  1. Meeting in-person with a mental health professional for individual or group mental health therapy
  2. Talking to a mental health professional via video chat
  3. Using an app on a cell phone or tablet to obtain mental health support
  4. Talking to a mental health professional over the telephone
  5. Information on seeing a therapist
  6. Attending a support group via an on-line platform

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Validated Screening Tools

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References